·   The easy availability of mother’s milk, its sterility, its temperature and its composition are ideal for optimal growth. Breast-feeding supports the emotional development of the child , through enjoyment of an essential and privileged relationship with his/her mother. Mother’s milk is the best food that can be offered to the infant from 0 to 4 months of age ; breast-feeding can be continued for 1 to 2 years providing that the child receives other necessaary foods;

        ·   The composition of breast milk develops according to the infant’s needs for growth ; the nutritional and immunological properties of breast milk are adapted to the child’s needs;

        ·    The quantity of breast milk is theoretically sufficient for the needs of the child unit the age of 4 to 6 months ; this depends on the effective stimulation of the nipple by sucking and on emptying the breast. Errors in the technique of breast-feeding, as well as malnutrition or a depressive state in the mother; can suppress breast milk production.


1.  Slow onset of lactation, sometimes taking 4 to 5 days.

Sucking stimulus of the nipple encourages the flow of the milk . The infant should be put to the breast as early as the first hours of life; indeed any colostrum it takes is nourishing and the smallest amount of sucking will help stimulate milk production.

To increase the production of milk , it is also necessary to:

      ·     feed the mother adequately;

      ·    encourage her to drink;

      ·     allow her to rest;

      ·     calm her and reassure her.

2.  Cracks in the nipple: small, superficial but painful coetaneous lesions, caused by chronic irritation or poor hygiene.

      ·   Prevention: clean hands, washing the nipple with cooled boiled water , keeping the nipple dry and covered.

      · Treatment: cleaning and drying the nipples , and the application of a 2% aqueous solution of eosin (not harmful for the infant).

       ·  Because stopping sucking suppresses lactation and causes painful engorgement of the breats and may cause mastitis or breast abscess, it is essential to continue feeding. This should be done by either continuing to offer the breast, or by expressing the breast gently and regularly to empty it . The milk can be given to the infant with a spoon.

3. Mastitis: infection of the mammary gland.

Early sings: swelling, heat and reddening , local or diffuse ; pain, sometimes considerable.


          ·  Wrapping in cold or chilled compresses;

          · anti-inflammatory drugs (aspirin, 3 g/day in three doses for 48 hours);

          · (e.g.spiramycin, 3 g/day in three doses for 7 days);

          ·  expressing the affected breast gently and discarding the milk;

          · continuing to offer the other breast to the infant.

4. Abscess: a collection of pus in the mammary gland.

Clinical signs of abscess formation: localised,very painful, hot and red.

 Treatment: in addition to the treatment for mastitis:

      ·  incision and drainage when the abscess is fluctuant;

      ·  the infant can return to the breast as soon as the abscess is cured.

5.  “My milk is not good” , or “ I don’t have enough milk”, or “My child does not want the breast any more”

Contraindications for breast-feeding are very uncommon and usually temporary. Basides , a healthy child is hungry. If the mother says that the child does not want the breast but “ accepts the bottle” , a reason must be sought.


    ·   explain the benefits of breast –feeding to the mother and find out,without making her feel guilty the reason for her choice,

     ·   if it appears that breast-feeding is not possible find out:

   -         if she has the material and financial means necessary for artificial feeding (allow for     2 to 3 kg of mild powder per month);

   -         whether she is capable of correctly preparing an infant formula;

     ·   if the child is ready for supplementation (3 to 4 months ) or for introduction of solids, recommend an adequate complementary food.

1            6. “ My child is always at the breast” or “ My child falls asleep whilst  at the breast”

Simple conditions must be met so that breast-feeding goes well:

·  the mother must be relaxed and comfortable, either sitting or lying down , and wanting to feed her baby;

·   the infant must be relaxed , not tired , not satiated , nostrils clear, not pressed against the breast;

·   the nipples must be cleaned before and after each feed;

·   the infant’s sucking reflex is stimulated by introducing the nipple into its mouth and by preliminary gentle stroking of the lips;

·  the breast should be gently squeezed to produce a few drops of milk for the infant to taste, a maneuver which will stimulate and maintain sucking and the letdown reflex;

·  the continuing secretion of milk should be maintained by gentle squeezing of the breast; the infant should be stimulated (e.g. by caressing, talking, singing and looking);

·  in this way, the infant will have an adequate meal , followed by a period of digestion , after which he will wake up for the next meal. The frequency of feeding is determined by the infant according to appetite, but for a term infant there should be at least six feeds per day in the first months; and there should be even more frequent feeds for premature infants . The infant who sleeps too much should be awakened for feeding; the more often he suckles, the more milk the mother will have . sugar water from a bottle must not be given.

7. “I must go to work” or “I have to go to the market”

A mother’s  social life and the economic needs of the family sometimes cause a lactating mother to leave the house to work or go to the market.

Sometimes she cannot or “will not” take her child with her. Although she must be encouraged (many mothers feed on demand and offer the breast whiled following their occupation), and although the lactating  mother must be spared the heavier takes, the health supervisor may sometimes have to agree to an occasional artificial feed , provided it is properly made up , according to the strict rules of hygiene.


 2               ARTIFICIAL FEEDING


1.                  1. Choice of milk:

      ·  do not use milk which is not adapted for infants;

      ·  most infant milk formulas are suitable for all infants; they consist of cow’s milk which has been modified and enriched to satisfy the normal nutritional requirements of infants and adapted to their physiological characteristics.

Infant formula may also be prepared at home in which case it is described as “home-prepared” (WHO International Code of Marketing of Breast-milk Substitutes, Geneva1981).

2.                  2.   Choice of water:

         ·  Clean drinking water will do , if possible boiled and filtered;

         ·  Of the bottled waters, only those with low mineral content are suitable.

3.                 3.   Choice of feeding utensils:


       ·  as far as possible , use a cup and spoon for easier cleaning;

       ·  glass feeding bottles (which can be more reliably washed and sterilized) with simple and clear graduation marks, preferably at 30 ml intervals;

       ·  bottles and teats should be carefully washed and boiled for 15 minutes each time before use; they should be sterilized in a pan or in a special sterilizer.

           4.   Making up the milk:

   ·  it must be very carefully prepared; the hands must be washed beforehand;

   ·  most tins of infant formula contain a measure marked with its capacity (usually 4.5g).The measure should be filled level , not heaped , say 4.5g in 30g water, 2 measures for 60g water, 3 for 90 g and so on;

   ·  put a little tepid water in the bottle , add the measures of infant formula; shake to dissolve; than add water up to the required amount;

    · carefully close the tin after use.

   · Remarks about the use of ordinary milk powder : after making up according to the instructions on the tin, it is necessary for infants up to 6 months of age to dilute it by putting one part of water in the bottle and adding two parts of reconstituted milk up to the quantity required; 5% sugar must also be added

          5. Quantities of milk to be given:

      ·    Apert’s rule:

Total quantity (ml) per 24h=weight in grams/10+200

This must then be divided by the number of feeds in the day (6 or 5 according to the age).

As soon as solid foods are introduced , this must be considered when calculating the total required.

     ·  Always prepare a little more than the child will take ; this avoids involuntarily restricting the amount taken; it is the child and its growth which ought to dictate the size of the feeds.

N.B. : do not keep the rest of the milk for the baby; give it to the older children

6.                  6.   Number of bottles:

       ·  At the beginning, the baby demands frequent feeds but by 6 to 7 months feeds 4 times a day, as adults do.

As with the size of the feeds , it is the infant and its rate of growth which determine their frequency.

Most children are happy with 6 to 8 feeds a day from the first days of life until they are 3 or 4 months old; they usually take 5 feeds a day between 4 and 6 months , and after that change to 4 feeds day.



Exclusive milk feeding in early life is adequate for growth but after 4-6 months of age , mother’s milk is not enough for  the infant’s requirements . It is therefore, absolutely necessary from 6 months or earlier that the infant has at least one non-milk feed each day.

Fig.1-How to feed a young child properly .

The first more solid feed (gruel) should be offered at about 4 months: this is known as supplementation and is usually well tolerated. At about 5 or 6 months, a more varied diet (e.g. vegetables ,meat ,fish, egg, cheese ,yoghurt) should be given; this may be accepted reluctantly, even refused.

Refusal may be a normal expression of the infant’s personality. When this happens, it is important to reassure the mother and to encourage her to persist.




         1.  Offer the breast from birth.

         2.  Breast-feed for 24 months if possible , and in any case until a complete and varied diet is accepted by the child.

       3. Bottle-feeding is potentially dangerous for all infants; whenever  bottle feeding is necessary, make feeds up very carefully , strictly obeying the rules of hygiene and composition.

         4.  Supplementary foods are not needed until 4 months of age . From then , or earlier if the weight curve falters, a supplement (e.g. gruel) should be given with a spoon.

        5. Gruels should be cereal-based and enriched with one or , preferably , several locally available foodstuffs , rich in proteins and fats.

         6.  From the age of 6 months, the infant should have the following once or twice a day:            


   Infants should have at least 4 meals a day until the age of 5 years.

         7. From 6 months, infants should take part in family meals , which should contain a         variety of foods; spices should not be given.

8.              Refusal to eat is very common in young children .  Check that the diet is well-balanced;     have the child weighed and carefully examined.

9.                  Sick children need semi-liquid diets which must be very nourishing and enriched with      fresh fats and sugar.

10.           Children with diarrhoea should be kept on the breast and given oral dehydration solution .

Meals should be nourishing , for example a mixture of curdled milk , oil and sugar, which does not aggravate the diarrhoea . If vomiting occurs , patiently persist with small quantities at a time by spoon , without giving more than a small bowlful (150-200 g).